Therapy of intoeing gait in cerebral palsy AOPA-Orlando-German Day, October 2010 F. Braatz MD, S. Wolf PhD

Introduction Internal Rotated Gait Functional & cosmetic problems  “squinting patella sign” (“knocking knees”)  internal foot progression  inefficient foot clearance  compensatory external tibial rotation  compensatory pelvic retraction

Operation D.E.12 Y.: CP, Diparesis, Derotation Femur35°., Evans, Hemstring Lengthening 07/08 Prae OP

Operation

Patient 1

V.T.12 y: Operation : 1) FDO right 30° left 20 ° 2) Chopartfusion 3) Rektus-transfer Proximal vs. distal Type

3D Gait Analysis

Proximal vs. distal Type

Team

Night Splint  Therapy overnight  Low-cost  Muscle-tone?  Stable hindfoot

KAFOs With hinges Night Splint

Foam Connected with a rod Night Splint

Night Splint-Foam

S.W.A.S.H. –MAO-Orthosis MAO Orthosis S.W.A.S.H. Orthosis

Soft Orthosis

Conservative Treatment  Botox ® (Typ A) : 1 Viole are 100 MU  Dysport ® (Typ A) : 1 Viole are 500 MU

3D gait analysis-MRI or CT 20° 6° 11° 22° 2° 17° static dynamic

Materials and Methods Function vs. Static deformity Patients –30 ambulatory patients with CP (18 male, 12 female) –age 11.6 ± 2.9 years Methods –Gait analysis: mean hip rotation –MRI: femoral anteversion Dreher et al. Gait Posture 2007;26:25–31 Braatz et al. JBJS (submitted)

FDO– technique intertrochanteric supracondylar

a) K-wires (*) placed proximally and b) Osteotomy parallel to the K-wires distally to the derotation line * * * * Femur Osteotomy FDO– technique

c) K-wires (*) are parallel aligned d) After derotation the angle between before the osteotomy and the the two K-wires (*) determines the derotation amount of derotation * * * * FDO– technique

Results Unpaired, two-tailed t-test for pre-post comparison. P-values <0.05 were regarded as significant. Exam/ParameterPre-OPPost-OPp-value Mean Pelvic Rotation-0.1 ± ± 6.60,892 Mean Hip Rotation in Stance13.8 ± ± 10.2< Foot progression angle11.1 ± ± 8.4< Table 2 – Pre- and postoperative results of dynamic examination in gait

Results Pearson’s correlation

Discussion Satisfactory results after FDO were reported [1] However, recent studies found over- and under-corrections [2] and recurrence [3] and discrepancy between intraoperative amount of derotation and functional outcome [2,4] Femoral anteversion is not useful as predictor for mean hip rotation in gait analysis Both, static and dynamic component should be taken into account when planning correction of internal rotation gait. [1] Ounpuu et al., (2002), J Pediatr Orthop., 22, 139–45. [2] Dreher et al., (2007), Gait Posture, 26, [3] Kim et al., (2005), J. Pediatr Orthop., 25, [4] Kay et al., (2003), J Pediatr Orthop., 23, 150–154.

Materials and Methods 48 children with spastic diplegic cerebral palsy and internal rotation gait underwent multilevel surgery including 85 FDOs 3D Gait Analysis pre- and postoperatively FDO intertrochanteric 42 supracondylar 43 Derotation (supramalleolar) 12 Multilevel soft tissue correction

Results Time (years)1,22,26,1 Mean (IRO)18,0-0,2-1,83,9 SD13,111,113,112,3 T-Test0,0000,7300,049 pre - post2 post1- post30,0000,022 pre - post30,000

Results

Literature  Patients having surgery prior to age 10 were more likely to show deterioration. Kim H, Aiona M, Sussman M ;J Pediatr Orthop Nov-Dec;25(6):  This trend toward internal rotation with hip flexion was apparent in 15 of the 18 muscle compartments we examined, suggesting that excessive hip flexion may exacerbate internal rotation of the hip. Delp, S.L. ; J Biomech May;32(5):

Conclusions  Conservative treatment, Physiotherapy, Orthosis  static and dynamic components  Proximal / distal type  asymmetry  Physical examination, X-ray, 3D Gait Analysis, CT/MRI

Thank You!